Answers I Really Want on Health Care Costs' Upward Spiral

Health and Human Services secretary Kathleen Sibelius has called for insurance companies to justify, explicitly and publicly, their premium increases. Now President Obama has gotten in on the action, calling for the aforementioned justification to be posted online for all to read.

OK, OK, we get it. Insurance companies make money dealing with people who are sick and vulnerable and facing the potential of giant mountains of dream-crushing medical bills. You know who else makes money there? Doctors. Once we get the explanation of the premium increases, I'd like to see the politicians press the doctors on their fees. My insurance company may raise my premiums, but at least they only do it once a year and give me some advanced warning. My insurance company, unlike my doctor, has never raised my costs mid-procedure while I was in the exam room with my pants dropped.

For the past 12 years, I've taken quarterly injections of prescription Depo-Provera, which I procure at a retail pharmacy for approximately $45. With my most recent dose, the doctor flatly refused to fill the prescription I have been taking since the late 1990's with no ill effects unless I came in for an unnecessary checkup, and also decided not to tell me she wouldn't refill it. That, I found out from my pharmacist when I went to pick up my medication and the pharmacist had no record of a refill. When I called my doctor's office to find out why I had no refill waiting, I was told the doctor would only provide me with my medication if I got it from her stock and agreed to schedule the unnecessary procedure during that call. The office staff had no idea what the medication would cost me. Note to politicians: it's hard to bend the cost curve if the doctors won't tell you the costs.

Fast forward to the appointment to get the injection administered. The nurse took me to the exam room and had me sign the usual raft of paperwork for getting an injection, then left to draw up the dose. I get the shot administered in my butt, and was all prepped with gluteal exposed when the nurse returned with the syringe in hand and told me, "The billing department says you're going to owe $50 for today's visit. Is that OK?" She's standing there with the medication I need all drawn up, I'm one cheek to the wind, and NOW the doctor's office tells me I have to pay $50 on the date of service, even though I carry insurance that has no copays. Say what you will about health insurance companies, and I'll grant that $50 isn't the $1,000-plus annual premium increases some folks are seeing, but at least the insurance companies give notice before they try to get more money out of policyholders.

I wonder what they would have done if I had told them that no, it wasn't OK. That I had assumed that they would use the procedure they'd used since my first appointment, where they run the claim through the insurance company and bill me a few weeks later, after insurance processes it, at which point I pay the entirety of the fee, minus the substantial "negotiated discount" (that, I will address in another post, along with cost-shifting). They had the medication drawn up. It's not like they could just put it back in the vial for the next patient if I walked out. In the end, since we keep a very little extra in the Health Savings Account, I told them I'd be able to pay the $50. On the way out, I asked the lady who took my money what the final bill would be, since $50 was getting pretty close to what I usually paid the pharmacy and the doctor combined when I brought my own meds. The office person looked up in her book, which she told me was way out of date, and said that the drugs would be $80 (mind you, I paid $45 at the pharmacy if they let me buy it there), but she didn't know if that was still the case or what the negotiated rate was.

To recap, after denying me the option to get my medication from my source of choice, the doctor's office can't tell me what they're going to charge me for it, but make me pay $50 toward that cost anyway, right now. And it's the insurance companies who have to answer for their deeds?

When I came home from being shaken down at the doctor's, I called my insurance company, UnitedHealthCare, to possibly try to figure out how much I was going to owe for this visit. The very helpful insurance company representative explained to me that more doctors are moving toward a policy of requiring payments on the date of service at the beginning of the year, when people haven't satisfied their policy deductible, regardless of what that policy deductible is. Because the doctor actually controls the negotiated discount, she couldn't tell me what the final bill would be, but gave me the information for filing an ethics complaint against my doctor if, once things settled down, I felt she had acted unethically.

Already, that was more answers from my insurance company than I got from the doctor. Insurance companies are being made the villains in the health care reform debate. Frankly, the insurance companies, while they definitely do some sleazy things, at least protect patients from some medical bills.

What seems to be lost in all this is that, aside from premiums, patients don't actually get bills from their health insurance companies. They get bills from their doctors. While premiums can be enormously high, the people you hear about who were bankrupted by illness were not bankrupted by their insurance premiums; they were bankrupted by doctor and hospital bills. You know, the things that your insurance company negotiates down on your behalf. If the President and the Health and Human Services Secretary get the answers they want from the insurance companies, I hope they turn their attention next to getting explanations for the actual medical bills from the people sending them: the doctors and hospitals.